What are the initial steps in a new cirrhosis workup?

Initial Workup for New Cirrhosis Diagnosis

The initial workup for newly diagnosed cirrhosis should include a comprehensive laboratory panel, imaging studies, and targeted evaluations to determine etiology, assess disease severity, and screen for complications. 1, 2

Laboratory Evaluation

• Complete blood count, comprehensive metabolic panel (including liver function tests, serum creatinine), coagulation profile (PT/INR), and urinalysis are essential baseline tests 3, 1
• Hepatitis panel including HBsAg, hepatitis B surface antibody, hepatitis B core antibody (HBcAb), HBcAb IgM (for acute cases), and HCV antibodies to identify viral etiologies 3
• Confirm viral load in patients who test positive for HBsAg, HBcAb IgG, or HCV antibodies 3
• Serum albumin, bilirubin, and prothrombin time are critical for calculating Child-Pugh score to assess disease severity 3, 1
• Serum electrolytes, blood glucose, blood calcium, and inflammatory markers to evaluate for metabolic abnormalities and infection 3
• Alpha-fetoprotein (AFP) testing can be useful in conjunction with imaging for hepatocellular carcinoma (HCC) screening, though it has limitations 3

Imaging Studies

• Abdominal ultrasound is the initial imaging modality of choice to assess liver morphology, identify complications, and screen for HCC 3, 2
• Contrast-enhanced CT or MRI of the abdomen may be indicated for further characterization of liver nodules or evaluation of vascular structures 3
• Transient elastography (FibroScan) can help confirm the diagnosis of cirrhosis and assess the degree of fibrosis 2, 4
• MRI is preferred when evaluating for inferior vena cava involvement or when contrast cannot be administered due to allergy or renal insufficiency 3

Etiology Assessment

• Ferritin and transferrin saturation to evaluate for hemochromatosis 2
• Autoimmune markers (ANA, ASMA, AMA) if autoimmune hepatitis or primary biliary cholangitis is suspected 2, 5
• Ceruloplasmin levels if Wilson's disease is suspected, particularly in younger patients 5
• Detailed alcohol consumption history and assessment for alcohol use disorder 4, 5
• Evaluation for metabolic syndrome components and non-alcoholic fatty liver disease 4, 5

Complication Screening

• Upper endoscopy to screen for esophageal and gastric varices 3
• Diagnostic paracentesis if ascites is present, with cell count, differential, culture, total protein, and serum-ascites albumin gradient (SAAG) calculation 6
• Cognitive assessment using validated tools to evaluate for hepatic encephalopathy 6
• Calculation of Child-Pugh and MELD scores to assess prognosis and determine transplant candidacy 1
• Abdominal ultrasound every 6 months for HCC surveillance 2

Special Considerations

• Liver biopsy should be considered when noninvasive testing is indeterminate, etiology remains unknown after initial workup, or when results would alter management 1, 7
• Brain imaging (CT or MRI) should be performed only for differential diagnosis in patients with suspected hepatic encephalopathy, not as routine 3
• Blood ammonia measurement may be considered in select cases but requires proper sampling technique (fasting patient, avoiding venous stasis, proper handling) 3, 6
• Patients with decompensated cirrhosis should be evaluated for liver transplantation 3

Common Pitfalls to Avoid

• Delaying diagnostic paracentesis in patients with ascites and confusion 6
• Overreliance on AFP alone for HCC screening without appropriate imaging 3
• Failing to consider multiple concurrent etiologies of liver disease 4, 5
• Unnecessary medications and surgical procedures that may worsen liver function 7
• Neglecting to screen for varices and other complications in asymptomatic patients 2, 4